Provider Demographics
NPI:1700025541
Name:ELLISON, MACEO RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:MACEO
Middle Name:RUSSELL
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 BELMONT LN
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2462
Mailing Address - Country:US
Mailing Address - Phone:630-752-0260
Mailing Address - Fax:630-752-9980
Practice Address - Street 1:610 BELMONT LN
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2462
Practice Address - Country:US
Practice Address - Phone:630-752-0260
Practice Address - Fax:630-752-9980
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-035394207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine